Brighton Gardens of Winston-Salem

The facility failed to ensure that one sampled resident had a physician's order and a completed assessment to self-administer medications. Specifically, there was no physician's order for bismuth subsalicylate, and the resident's medication was found at their bedside without the required documentation for self-administration.

The facility failed to ensure a resident had a physician's order and a completed assessment to self-administer medications including cough medicine, stool softener, and medications for stomach discomfort and diarrhea. Additionally, medications like bismuth subsalicylate and loperamide were found unsecured on the resident's bedside table despite the resident being assessed as not capable of self-administration.

The facility failed to ensure one of five sampled residents received a required second-step tuberculosis (TB) skin test following admission. While a first-step test was documented at admission, there was no evidence of the subsequent required testing in the resident's record.

The facility failed to provide adequate supervision in the special care unit (SCU) according to residents' assessed needs. Specifically, supervision was insufficient for a resident with a history of aggression and wandering, as well as a resident with a history of falls resulting in injuries.

The facility failed to ensure that one of five sampled residents received the required second-step tuberculosis (TB) skin test following admission. While a baseline test was documented upon admission, there was no evidence that the subsequent required testing was completed or audited for compliance.

The facility failed to ensure that 8 ounces of milk was served to residents in the Special Care Unit (SCU) three times daily. Review of the menu showed milk was not listed for lunch or snack times, and observations confirmed that many residents were not provided milk during meal services. Additionally, a supervisor stated they were unaware of the requirement to provide milk to each resident three times per day.

The facility failed to ensure that water was served to each resident at each meal, in addition to other beverages.

The facility failed to ensure 8 ounces of milk was served three times daily to residents in the Special Care Unit (SCU). Review of the menu showed milk was not listed for lunch or snack times, and observations confirmed that staff only poured milk for residents who did not decline it.

The facility failed to maintain complete tuberculosis (TB) testing documentation for multiple staff members. Specifically, records for Staff C, Staff D, and Staff F lacked documentation of a second TB skin test or a required read date. Management was also unable to identify these missing requirements during the review.

The facility failed to ensure that 3 out of 6 sampled staff members were tested for tuberculosis disease using the required two-step skin test. Specifically, one staff member's second skin test was not documented as being read, and another staff member lacked documentation of a second skin test entirely.